Community Case

Saeed Awan

Case
51 year old male

Nausea Fatigue General Malaise Hb 172 Ferritin 1000

Weight loss Pain Right Upper Quadrant Night Sweets, Pyrexia Loss of Appetite Loose Stool - One month

Past Hx

Recently diagnosed Hypertension

Altace 5mg O.D

Smoking: 2-3 packs/day for years No Alcohol

Family History

Father (D) - Bowel Carcinoma Mother (D) - 1HD + DM Brother (A) - Prostate Cancer

Pale + unwell, pyrexial H.R 78 B.P 120/80 Chest Bilateral Crepts (Basal area) Abdomin Hepatomegaly (Slight tender)

CBC

Hb 121 WBC 14.1 LFT ALP 161 ALT - 58 LDH 218

Ultrasound

Large mass Right lobe of liver Solitary lesion with multiple septation
11 x 13 cm Right lobe of liver

C.T Scan

Benign cyst (Left Kidney) Left Adrenal small adenoma

? Hepatocellular carcinoma or hepatoma

Blood Culture Anaerobic streptococcos Ampicillin + Gentamycin + Clindamycin Endoscopy Upper G.I Normal Colonoscopy Polyp 20cm Polypectomy Irregular area at 25cm Biopsies taken Pus/white exudate came out from biopsy site

Sigmoid Diverticulitis + area draining purulent matter Biopsy- No evidence of malignancy Percutanous liver biopsy
Pus organism streptococcus

Pyrexial Hb 103 WBC 14.8 LFT ALP Elevated

C.T Scan

Right Pleural effusion + Atelactasis (base) Mutiloculated fluid collection in right lobe of liver

Operative Finding

Massive Swelling underneath the capsule Right lobe superiorly 900cc pus Dense Adhesions Post. between liver and abdomin wall. Dense adhesions between hepatic flexure and inferior surface of right liver small abscess. JP x 1

Drain surrogate x 3 Thickened sigmoid colon

Pleural Effusion Taping (1800cc) C.T scan

5 x 5cm lesion

Clinically well Discharge - 25 Sept/03

Liver Abscess

Incidence

8-20 cases per 100,000 persons.(slight recent increase) Higher incidence in crohns disease (114-297). Male to female ratio: 2 : 1 Most commonly in the fourth decade. A small peak neonatal period.

Types
Pyogenic

Bacterial Fungal immunocompromised and indwelling biliary stents long term antibiotics.

Amoebic

Tropical and sub tropical environments

Etiology

Biliary disease - 30 to 60 % Infection via the portal system (portal pyemia) - 25% Hematogenous (via the hepatic artery) - 15% Cryptogenic - 20% Contiguous spread from localized infection of the gall bladder, or subhepatic abscess. Complication of liver transplantation, hep. ar. embolization.in the treatment of hepatic neoplasm. Secondary infection of blunt or penetrating trauma.

Pathophysiology
Bacteris gain access o liver though portal vein or hepatic artery or direct extension from the contiguous organs or from the biliary tract. Hepatic clearance appears to be a normal phenomena in healthy individuals. Kupffer cells lining the hepatic sinusoids clear bacteria so efficiently that infection rarely occurs. However with biliary obstruction, poor perfusion or microembolization organism proliferation, tissue invasion and abscess formation can occur.

Pathophysiology (cont..)

Abcesses
Solitary 50 to 60% Multiple

Right lobe 60% Left lobe 10 to 15% Bilober 20%

Microbiology

Symptoms and Signs of Pyogenic Liver Abscess

Symptoms Abdominal Pain Fever Percentage 89-100 67-100 Signs Normal findings Right upper quadrant tendreness Hepatomegaly Mass Jaundice Chest findings Percentage 38 41-72

Chills Anorexia Weight loss Cough Pleuritic chest pain

33-88 38-80 25-68 11-28 9-24

51-92 17-18 23-43 11-48 -

Lab Studies
Complete blood cell count Anemia 50-80% Leukocytosis 75-96% Bands of more than 10% - 40% Blood culture Electrolytes, BUN, Creatinine

Liver function tests

An elevated alkaline phosphatase 95-100% An elevated serum AST and ALT 48 60% An elevated bilirubin 28-73% A decreased albumin level (<3 g/dL) and increased globulin value (>3 g/dL) Prothrombin time is elevated in 71-87%

Imaging Studies
Chest radiograph

Nonspecific findings may include an elevated right hemidiaphragm, subdiaphragmatic air-fluid level, pneumonitis, consolidation, and pleural effusion If gas-forming organisms are present, the abdominal x-ray film might show evidence of intrahepatic air, air-fluid levels, or air in the biliary tree. 80-100% sensitive. A round or oval hypoechoic mass is consistent with pyogenic abscess.

Abdominal radiograph

Ultrasonography

Imaging Studies (cont..)

CT scan

Has become the imaging study of choice for detecting liver lesions. Pyogenic liver abscesses are not enhanced on images after intravenous contrast administration. Findings can help reliably detect masses larger than 2 cm. The sensitivity of the findings ranges from 50-80%; however, they lack specificity. Diagnostic aspiration under U/S or C.T guidance drainage catheter placement

Radionuclide scan

Diagnostic procedure

Treatment
Most dramatic change in the treatment of pyogenic liver abscess has been CT guided drainage. Prior to this open surgical drainage was the treatment (high mortality) Current approach include three steps 1. Antibiotic therapy 2. Diagnostic aspiration and drainage of the abscess 3. Surgical drainage in selected patients

Indications for Surgery

Abscess not amenable to percutaneous drainage secondary to location Coexistence of intra-abdominal disease that requires operative management Failure of antibiotic therapy Failure of percutaneous aspiration Failure of percutaneous drainage

Contraindications to Surgery

Age older than 70 years Multiple abscesses Polymicrobial infection Presence of associated malignancy or immunosuppressive disease Coexistence of other multiple and/or complicated medical problems or conditions

PYOGENIC HEPATIC ABCESS Clinical suspicion Empiric Broadspectrum Antibiotics Computer topography, diagnostic aspiration Intraabdominal source ? No Solitary or few, large abscesses Percutaneous Drainage and Antibiotics Multiple small abscesses Antibiotics alone Yes Surgical Drainage Identify and Treat Source

Treatment Failure

Identify and Treat Source

Treatment algorithm for patients with pyogenic hepatic abscess

AMEBIC ABSCESS Clinical suspicion Computed Tomogrpahy Indirect hemagglutination assay Oral Antiamebicidal therapy

No additional Rx for uncomplicated abscess

Large, high risk, superinfected, or unresponsive abscesses Percutaneous Drainage

Rupture

Surgical Drainage

Treatment algorithm for patients with amebic abscess.

Complications

The complications of liver abscess result from rupture of the abscess into adjacent organs or body cavities. These include both pleuropulmonary and intra-abdominal types. Pleuropulmonary complications are the most common and have been reported in 15-20% of early series. These include pleurisy and pleural effusion, empyema, and bronchohepatic fistula. Intra-abdominal complications are also common. These include subphrenic abscess and rupture into the peritoneal cavity, stomach, colon, vena cava, or kidney. Rupture into the pericardium or brain abscess from hematogenous spread is rare.

Outcome and Prognosis

Untreated, pyogenic liver abscess is associated with 100% mortality. Early series reported a mortality rate of greater than 80%. With early diagnosis, appropriate drainage, and long-term antibiotic therapy, the prognosis has improved markedly, with mortality rates in the range of 15-20%. The 4 poor prognostic factors are as follows: Age older than 70 years Multiple abscesses Polymicrobial infection Presence of associated malignancy or immunosuppressive disease

Thank you